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1 1 ** Clinical Training Requirements Checklist for Conditionally Accepted Fall 2015 Nursing Students** The following checklist outlines required documentation for conditionally accepted Fall 2015 nursing students. Please read this carefully. Failure to comply with the submission of any of these documents will result in a denial of participation in clinical training Criminal Background Check AND 12-Panel Urine Drug Screen Please complete the attached Authorization for Release of Information & Records (page 4) for submission directly to Investigative Associates & Consultants (IAC). You may mail, , fax or deliver your release in person. Once submitted, IAC will contact you to discuss payment options. The fee varies depending on how many names and addresses are listed on your Social Security Trace. Acceptable forms of payment are cash, personal check or money order. Once payment is made you will receive the form for your drug screening. The drug screening can be done at IAC. For additional lab locations please consult with representatives at IAC. You must advise IAC of which location you intend to use for your drug screen in order to receive the appropriate form. You should complete the drug screening within 3 days of receiving the form. Deadline for payment to IAC is July 15, Please check your DCCC regularly for updates and additional information. For further information or questions, please contact Investigative Associates & Consultants directly. PLEASE NOTE: IT IS EACH STUDENT S RESPONSIBILITY TO COMPLETE THIS PROCESS AND FOLLOW UP WITH IAC IF NECESSARY. Investigative Associates & Consultants 3796 Vest Mill Road Winston-Salem, NC (336) ******************************************************************************************************************* The remaining documentation should be turned into Nancy Harrison (contact information is below). Do not send to admissions or to the address listed above. It is strongly recommended to send or deliver all of these materials well in advance of any deadlines so that any omissions or incomplete records may be corrected. All forms are to be submitted at the same time; incomplete packets will not be accepted. If you mail the documents, please call to verify that the materials have been received. Nancy Harrison Briggs Technology Building Davidson County Community College P.O. Box 1287 Lexington, NC (336) x6180 (336) fax The worksheet on page 8 is provided for your convenience in preparing your documentation.

2 2 Checklist of Documentation Medical Form PLEASE COMPLETE THESE FORMS CAREFULLY, COMPLETELY, KEEP A COPY, AND RETURN THE ORIGINAL TO NANCY HARRISON. North Carolina laws and Davidson County Community College policy require documentation of immunization information. Any and all attachments to these forms should include your name and DCCC student ID number for identification purposes. Report of Medical History, Family & Personal Health History- to be completed by student AND if under 18 years of age, also signed by parent/guardian. Immunization Record (documentation for immunizations can be on provided on the enclosed health form or on another form signed or stamped by a clinical agency). All documentation must include an authorized signature or clinic stamp. o Section A: Documentation needed for this section is for the immunizations listed below only. o Section B: o Section C: Tetanus/Diphtheria/Pertussis (Tdap) Vaccination Documentation of a Tdap vaccination within the last 10 years is required Two-Step Tuberculin Skin Test (TST) Step One: First test to be administered and initial result to be read by trained healthcare professional within 48 to 72 hours. If result is positive: TB questionnaire & chest x-ray required. If result is negative: Proceed with Step Two: Step Two: Second test to be administered in 1 to 3 weeks of first test. If second test result is positive: TB questionnaire & chest x-ray required. MMR (Measles, Mumps, Rubella) Vaccinations: 2 doses, 4 weeks apart OR positive serum titers for each disease. PLEASE NOTE: You must provide evidence of immunity by serum titers or proof of 2 doses of live measles, 2 doses of live mumps and at least 1 dose of live rubella. Single doses of measles and mumps vaccines are not sufficient. History of disease, even from a physician, is not acceptable. Hepatitis B Vaccinations: 3 doses over a 6-month period Dose #2 one month after dose #1, dose #3 approx. 5 months after #2. PLEASE NOTE: The first two doses are required by the posted deadline. Chickenpox (Varicella) Vaccinations: 2 doses, 4 weeks apart OR positive serum titer. PLEASE NOTE: History of disease, even from a physician, is not acceptable. Flu documentation needed in this section Annual Seasonal Influenza Vaccination (available each fall) No documentation needed in this section

3 3 Physical Examination- to be completed and signed by a health care provider no more than 12 months prior to the first day of class. o Must be completed by a physician, physician assistant, or nurse practitioner. o The statement box Only for Students Admitted to a Health Sciences Program must be completed as well. o These forms must be signed and the address and telephone number of the examiner must be included and legible. o On the physical examination section of the medical form HGB or HCT, Urinalysis, and STS are not required. o It is your responsibility to ensure that the health provider completes this section. The health provider decides if the two blocks on the physical examination form labeled if required need to be completed. Statement of Policy Regarding Clinical Training Be sure you read and understand the DCCC policies regarding placement for clinical training. Please complete the attached form (page 6) and return to Nancy Harrison. Statement of Understanding Regarding Seasonal Influenza Vaccination An annual seasonal flu immunization is required every fall. Please complete the statement of understanding form (page 7) and return to Nancy Harrison. Documentation of Nurse Aide I Training (not a requirement for LPN-to-ADN option) State-approved training programs must be a minimum of 75 hours and include 16 hours of supervised clinical training. Short term programs (e.g., 1-2 days) are not acceptable. There will be no exemptions from this Nurse Aide I requirement (e.g., paramedics). Provide transcript or certificate of completion for an acceptable Nurse Aide I course and return to Nancy Harrison. Go to for a list of acceptable courses. Only courses on this list will be accepted. Proof of Current Nurse Aide I Listing on the North Carolina Nurse Aide Registry (not a requirement for LPN-to-ADN option) Provide printout of verification of a current NA I listing without findings from the NCNAR website at https://www.ncnar.org/verify_listings1.jsp#who and return to Nancy Harrison. Students currently enrolled in an NA I class as of July 1, 2015, must submit evidence of enrollment in an approved NA I class by July 15, Students currently enrolled in an NA I course that will not be completed by July 15, 2015, must submit documentation of NA I training and proof of current NA I listing on the NC Nurse Aide Registry by August 17, Basic Life Support (CPR) Certification for the Healthcare Provider* *Nursing, Medical Assisting, and Surgical Technology students ONLY Training must include 1-man and 2-man CPR for adult, child and infant. Only American Heart Association CPR training is acceptable. Provide front and signed back copy of CPR certification card and return to Nancy Harrison. NOTE: The student is also expected to create and maintain a portfolio of the documents listed above and may be asked to provide copies of certain documentation at clinical sites.

4 4 INVESTIGATIVE ASSOCIATES & CONSULTANTS, INC. (In association with Davidson Community College) AUTHORIZATION FOR RELEASE OF INFORMATION & RECORDS I,, understand that in consideration of my application for a clinical rotation at a healthcare facility associated with Davidson Community College, an investigation will be conducted. I authorize Investigative Associates & Consultants, Inc. to conduct such an investigation, which may include, but not be limited to, the gathering of information regarding verification of prior employment, education, references, consumer credit history, driving history, and any criminal history which may be in the files of any state, federal, or local criminal justice agencies. I understand that I have the right to request, in writing, a complete and accurate disclosure of the nature and scope of this investigation. I authorize Investigative Associates & Consultants to transmit a copy of my background investigation to other entities such as hospitals or clinical sites where I may participate in additional clinical rotations. I understand that the information requested below regarding sex, race, date of birth, and maiden name is for the sole purpose of gathering information accurately. Mo. Day Yr Last First (BIRTH) Middle Social Security # Date of Birth (Please print Full Name Do not use initials) Maiden, Previous Married, and all other Driver s license # State Sex Race Alias names used Daytime Telephone Number Address Yr Mo Present Address City/State Zip/County How long? List all other addresses used for the past 7 years - use additional page(s) if needed. Yr Mo Previous Address City/State Zip/County How long? Yr Mo Previous Address City/State Zip/County How long? Yr Mo Previous Address City/State Zip/County How long? If you have lived in the following states within the last seven years; Alabama, Arkansas, District of Columbia, Georgia, Idaho, Iowa, Massachusetts, Minnesota, New Hampshire, New Jersey, South Dakota, or Virginia, you will be asked to complete an additional form at the time of your interview. If you have lived in Delaware, Nevada, Ohio, South Dakota, West Virginia or Wyoming, you will need to obtain the appropriate fingerprint card(s) at the time of your interview. A telephone facsimile or photographic copy of this authorization shall be as valid as the original. PROGRAM - COURSE Applicant s Signature Date Investigative Associates & Consultants, Inc Vest Mill Road Winston-Salem, NC Telephone: (336) Telefax: (336)

5 5 DAVIDSON COUNTY COMMUNITY COLLEGE STATEMENT OF POLICY REGARDING CLINICAL TRAINING IN THE FOLLOWING PROGRAMS Associate Degree Nursing Central Sterile Processing Healthcare Interpreting Histotechnology Medical Assisting Nurse Aide Phlebotomy Surgical Technology Cancer Information Management Emergency Medical Science Health Information Technology LPN-to-ADN Option Medical Laboratory Technology Pharmacy Technology Practical Nursing Education Students accepted into the above programs must meet the standards of both the College and the contracting clinical site in order to participate in the appropriate clinical training for the program. Each clinical site where a student receives training reserves the right to refuse clinical training to any student found to be unacceptable according to that site s policies and regulations. Reasons for refusal could include, among other considerations, a positive drug screen, an incomplete immunization record, a documented police record indicating convictions for drug or alcohol related charges, child abuse or molestation, burglary, larceny or other convictions deemed inappropriate to the particular clinical setting. Clinical sites require a law enforcement record check prior to a student s placement for training at that site. Convictions for certain crimes and/or evidence of drug use may disqualify students from participating in clinical experiences. Although an applicant's criminal background will not prohibit admission to the college or a health sciences program, the inability to participate in clinical experiences would prohibit the student from progressing and completing the program successfully. No applicant shall be denied admission to clinical training due to age, gender, race, religion, national origin or handicap. The student must conform to, and be subject to, all policies and regulations of the assigned clinical site. The site reserves the right to end clinical training of any student found violating rules, policies or procedures. This suspension of clinical training can only follow consultation between personnel at the clinical site and college personnel. Written justification must be provided for such suspension. The clinical site and college personnel reserve the right to take appropriate immediate action when necessary to maintain the proper and safe operation of its facilities and the safety of clients in the clinical site. Students in clinical training sites who exhibit impaired job performance or impaired thinking (the inability to make appropriate judgments and/or to carry out functions appropriately) or who exhibit other signs of possible use of alcohol or controlled substances may be requested to provide a urine or blood sample for testing in order to determine whether or not there has been use of drugs or alcohol. Failure to provide body fluid samples will be interpreted as supportive of impairment. Test results indicating use of controlled substances or alcoholic beverages will be grounds for suspension from the program.

6 6 DAVIDSON COUNTY COMMUNITY COLLEGE STATEMENT OF UNDERSTANDING REGARDING CLINICAL TRAINING I verify that I have read and understand the policies of Davidson County Community College regarding placement for clinical training. I understand that conviction for certain crimes under the law, positive drug screen results, or incomplete immunization records may prevent my ability to obtain clinical training, licensure and/or employment. I also understand that the inability to participate in clinical experiences would prohibit the progression and successful completion of the program. I understand that it is a privilege to be accepted as a student in these above programs of study and that the sensitive nature of the programs require that students participating in clinical practice should be free from any controlled substances which might impair the abilities of the student to perform his or her duties in such a setting. This is true whether the substances are prescribed or not. In view of the foregoing, I affirm that I do not currently use any illegal drugs; nor do I abuse alcohol or prescribed or non-prescribed medications. During my clinical practice involvement as a student at Davidson County Community College, I agree to voluntarily give body fluid samples should the instructor or manager of the clinical unit where I am assigned so request on the basis of impaired job performance. I understand and agree that refusal to provide samples, when requested, will make me subject to disciplinary actions as provided in the rules and regulations of the College. This could result in suspension from the program. I further agree that the College shall be relieved from any liability and cost associated with the taking and testing of samples of my body fluids which shall be done by independent medical or laboratory personnel. FURTHERMORE, I authorize the release of the results of these tests, examinations, and health records to the designated Davidson County Community College representatives and affiliated sites. By this authorization I do hereby release the previously designated doctors, medical personnel or employees of the College and clinical agency from any and all liabilities arising from the release or use of the information derived from or contained in my physical examination and test results. I also authorize Davidson County Community College and affiliated sites to conduct any investigation of law enforcement records necessary and pertinent to placement with a clinical training site. I verify that I have read and fully understand the foregoing statement prior to my admission into the program and that I have executed this agreement of my own free will and volition without any compulsion or coercion whatsoever. Signature Print Name Date

7 7 DAVIDSON COUNTY COMMUNITY COLLEGE STATEMENT OF UNDERSTANDING REGARDING SEASONAL INFLUENZA VACCINE NAME: Program (please check appropriate box below): Associate Degree Nursing Central Sterile Processing Healthcare Interpreting Histotechnology Medical Assisting Nurse Aide Phlebotomy Surgical Technology Cancer Information Management Emergency Medical Science Health Information Technology LPN-to-ADN Option Medical Laboratory Technology Pharmacy Technology Practical Nursing Education Please sign below. Your signature indicates your understanding of the flu vaccine requirements. CONSENT I understand that I will be required to take this vaccine annually upon its availability in the fall. I understand that, as with all medical treatment, there is no guarantee that I will develop immunity or that I will not experience an adverse effect from the vaccine. I understand that I will be responsible for the cost of the vaccine. I will maintain this documentation in my personal records and turn in copies to the College. Signature: Date:

8 8 CLINICAL TRAINING REQUIREMENTS WORKSHEET! Health History and/or Physical Examination form(s)! Two-step Tuberculosis screening records. Please note: Step One: First test to be administered and initial result to be read by trained healthcare professional within 48 to 72 hours. If result is positive, TB questionnaire & chest x-ray required. If result is negative, proceed with Step Two. Step Two: Second test to be administered in 1 to 3 weeks of first test. If second test result is positive: TB questionnaire & chest x-ray required. Step 1 date of application: Step 2 date of application: Step 1 date of reading/results: Step 2 date of reading/results:! MMR (Measles, Mumps, Rubella) Vaccinations: 2 doses, 4 weeks apart OR positive serum titers for each disease. PLEASE NOTE: You must provide evidence of immunity by serum titers or proof of 2 doses of live measles, 2 doses of live mumps and at least 1 dose of live rubella. Single doses of measles and mumps vaccines are not sufficient. History of disease, even from a physician, is not acceptable.! Varicella (chicken pox) titer providing proof of immunity, or series (2 doses) of vaccine! DTP (Diphtheria-Tetanus-Pertussis) or Td (Tetanus-Diphtheria) and polio vaccine (childhood immunizations) records, with a Tdap booster dose every 10 years! Hepatitis B series (3 doses)! Annual seasonal influenza vaccination (fall, 2015)! Signed copy of the Statement of Policy Regarding Clinical Training! Signed copy of the Statement of Understanding Regarding Seasonal Influenza Vaccine! Criminal Background Check & 12-panel Urine Drug Screen per Investigative Associates & Consultants! Copy of transcript or certificate of completion of Nurse Aide I training (does not apply to LPN-to-ADN option)! Signed Basic Life Support (CPR) certification for the Healthcare Provider (exp. date )! Proof of current Nurse Aide I listing on the North Carolina Nurse Aide Registry (does not apply to LPNto-ADN option)

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